Dealing with casualties from a terrorist attack

November 3, 2004

Doctors from one of the two hospitals closest to the Madrid bombings have described their experience of March 11th, 2004 in an article published today in Critical Care. Dr Gutierrez de Ceballos and colleagues explain how they organised the hospital to deal with the influx of casualties, as well as analysing severity of injuries and survival rate. The lessons they learnt are invaluable while future terrorist attacks remain a threat.

Doctors from one of the two hospitals closest to the Madrid bombings have described their experience of March 11th, 2004 in an article published today in Critical Care. Dr Gutierrez de Ceballos and colleagues explain how they organised the hospital to deal with the influx of casualties, as well as analysing severity of injuries and survival rate. The lessons they learnt are invaluable while future terrorist attacks remain a threat.

Dr Gutierrez de Ceballos and colleagues are based at the Gregorio Mara??n University General Hospital (GMUGH), the largest public hospital in Madrid. Their article warns that overtriage can inundate hospitals, compromising care of those who need it most. They also demonstrate how immediate organisation to evacuate patients and setting up triage and information centres helped prevent medical staff being overwhelmed, enabling them to save the lives of more than 80% of the critically injured.

The Madrid explosions injured more than 2000 people, and 312 of these casualties were taken to GMUGH. The authors conclude that this was probably overtriage to GMUGH, which could have been life-threatening if less medical staff were available. They write, ”the bombings occurred shortly before the start of a midweek workday when most clinicians and medical personnel were on their way to work or already in hospital, and night shifts were still on duty. This, together with empty operating rooms and personnel waiting for the first scheduled cases, proved decisive for the adequacy of the medical and surgical response at GMUGH and other hospitals. Had the blasts occurred just one hour later, the whole situation would have been much worse and very difficult to handle.”

Eric R Frykberg, Professor of Surgery at the University of Florida College of Medicine and the author of a number of articles related to this subject, endorses their findings in his commentary also published in Critical Care. He emphasises ”preventing as much as possible the arrival of so many noncritical victims to a definitive care hospital by performing triage first at outside sites before allowing them to inundate the hospital.”

Of the 312 patients taken to GMUGH, just 91 were hospitalised, 89 of them (28.5%) for more than 24 hours. Sixty-two patients had superficial bruises or emotional shock. 41% of the 243 patients with more severe injuries had suffered perforation of the ear drum, 40% had chest injuries, 36% had shrapnel wounds. Fractures, first or second degree burns, eye lesions, head trauma and abdominal injuries were also common. The pattern of injuries is consistent with other terrorist bombings. One of the unusual aspects of GMUGH’s experience was the large number of blast lung injuries (BLI). The 63% incidence (17 cases) of BLI seen in GMUGH’s critical patients was higher than previously published results, and ”probably reflects a bias in triage of many severely wounded patients to our hospital, which was closest to the blasts”, say the authors.

32 victims sent to GMUGH needed 34 surgical procedures on the day of the blast. Twenty-nine casualties (12% of the total or 32.5% of those hospitalised) were deemed in critical condition, and two died within minutes of arrival. Twenty-seven casualties were admitted to intensive care units, and were assessed with the Injury Severity Score (ISS) and Acute Physiology And Chronic Health Evaluation (APACHE) II scales in the first 24 hours. Three patients later died of their injuries.

GMUGH dealt with this influx of severely injured patients ”with virtually no warning” by immediately performing all of the ”appropriate procedures”, says Frykberg. According to Gutierrez de Ceballos, ”Immediate action was taken to cancel all scheduled surgical intervention and 161 hospitalized patients were discharged in less than 2 hours. A number of patients in the intensive care unit and surgical intensive care unit were evacuated to intermediate-care units. The 123 patients under observation at the Emergency Department (ED) before the blasts occurred were either discharged home when appropriate or transferred to the wards, and only 10 of them remained at the ED at 9.30 a.m. All elective diagnostic procedures were deferred. At the same time, the Teaching Pavillion, adjacent to the ED, was set as information center for the families, authorities and the media. Triage was performed by senior faculty at the entrance to the ED, and lasted until around 10.30 a.m.”

The authors conclude, ”All in all, common sense, diligence in the triage of patients and serenity seemed to prevail after the initial unavoidable chaos and emotional trauma common to these situations. There was in fact an abundance of medical teams, nursing staff, and resources to treat the critically injured, and no critically injured patient had a delay in treatment.”